Tuesday, August 17, 2010

I love e-things. I am a gadgety sort of person – and yes, I do have a fancy super-duper iPaddy kind of thing. I consider myself to be techno-savvy, and run my private practice with an almost paperless electronic records system. I am an early adopter of many technologies, and will always try new things. But I am not so convinced on e-Health. Why?

e-Health is all the rage. The federal government even has a special taskforce called NEHTA (National e-Health Transition Agency) which is dedicated to wasting investing money in this area. It is all about "transforming and revolutionising" the way we practice medicine.

I don't want to transform and revolutionise anything. I just want to be able to treat my patients better and more easily. This does not require me to have access to every piece of medical documentation on a patient since they were born. It does not require me to be able to access a full medication list and prescribe remotely to a patient on the other side of the country. It also does not require me to videoconference with every patient or doctor in the country.

We have many, many technologies today which make things easier. Often they are the simplest things, and usually they are so pervasive and useful that we take them for granted, like the telephone.

Now, it would be remiss of me not to point out that we are in the latter half of a Federal Election campaign here in Australia. What prompts this post is not the lack of comprehensive health-care policy discussion from either major political party so far, nor the incessant, disproportionate focus on mental health whenever any health funding is mentioned. Julia Gillard's health policy is "Doctors are expensive so let's replace them with technology, physician assistants, nurse practitioners and allied health." Tony Abbott's health policy is "It's too hard let's just hand it to local communities."

But it does bug me that Julia Gillard can stand up and say that she will fund a revolutionary new "Online Consultation" service with a new Medicare Item Number. This is a government whose Health Minister, Nicola Roxon, has been trying very hard to slash item numbers such as those for Cataract Surgery, Obstetric Services, Coronary Angiography, Joint Injection, and Injection Sclerotherapy for Varicose Veins (MBS Website). There is no doubt that this is merely an "election sweetener" for rural GPs and rural voters, and those employed in the technology infrastructure sector.

Steady uptake in Telepsychiatry.

An item number already exists for Telepsychiatry consultations (Items 353-370), and uptake has been gradual - pushed primarily by a small number of psychiatry groups. One might think that psychiatric consults are ideal for videoconference but remember that a great deal of patient interaction is via non-verbal communication and behavioural cues, which even videoconferencing cannot replicate. The RANZCP has guidelines as to how they recommend Telepsychiatry be used.

But much as videoconferencing might be the poster-boy of this type of technology, it ignores the fact that there are many simpler and commoner means by which clinical information is communicated between patients, GPs and specialists, such as email and the telephone.

For example, this policy announcement outlines a scenario whereby a patient might conduct a combined GP visit with an online videoconference to an oncologist. Presumably this is encouraged by the GP and the Oncologist both being able to claim an item number for this consultation.

The key parts of this conference are that first of all, the patient knows that the oncologist exists and is not a figment of the GP's imagination (but there are other means of achieving this) and secondly, the GP is able to discuss the patient's individual treatment plan with a distant oncologist (which is best done in private away from the patient). Given that the private conference is the most important, why restrict any Medicare benefits to a combined patient-GP-specialist consultation?

Currently, patients who will not or cannot travel to see an oncologist can be cared for by a GP or local physician, with instructing care issued by a remote oncologist by much more prosaic technologies as mail, or telephone. Video-conferencing is sometimes used for multidisciplinary team meetings. Realistically, the video adds very little to such meetings or discussions, so it is silly to think that an item number must insist on the conference occurring via video-link. In that setting, should Medicare benefits be available for specialists who spend their time giving advice over the telephone, or reviewing patient files and sending a letter of advice?

If that is the case, then I should be paid Medicare benefits for all the GP queries that I get over the phone, and all the paperwork that I perform organising a patient's care in between physically seeing them. Instead of seeing review patients, I could just check their results, give them a phone call, and lodge the Medicare claim. Is that good or bad? It sure would make my job easier. I could see more patients. It would be significantly cheaper and more convenient for the patient. Even better, if the new Government were to fund practice nurses for specialists, then I could delegate the job to my nurse!

First patient to survive a stroke without side effects?
BULLSHIT! What a way to blow your own trumpet!

Why is it that when you slap a computer with the Internet on it, everything suddenly becomes "Telemedicine"? Since the telephone was introduced doctors have been giving instructions from remote. Is that "Telemedicine?" For years I have been reviewing photos of patients and their X-Rays via email from distant GPs. Am I on the cutting edge of Telemedicine? I have had remote PACS access to a number of hospitals and reviewed films from home. I have advised surgeons and GPs in other towns how to perform surgical procedures over the telephone. Should I be on the news because I am a frontier Tele-surgeon? I don't think so... this is just part of the pervasiveness of communications technology into common life, as well as medicine.

I don't know about you, but this thing
would scare the crap out of me.

My advice, Julia – scrap the "Online Consultations" rubbish and bring in an item number that pays doctors for all the organisational work involved in-between face-to-face patient visits, allow doctors to be paid for telephone consults, advice and services, and don't bother wasting money on teaching doctors to videoconference when they will use it perhaps once of twice a year just for fun. Spend the money on secure integrated email for all doctors and practices. Oh, and funding for specialist practice nurses please.

3 comments:

How well put. The political world is full of people taking bad advice on medical matters - telemedicine is just one of them. As you have written, there is a place for things like email, remote access to Xrays and phone calls in medicine but the idea of routine videoconferenced consultations or even medical case conferencing is of minimal utility - certainly not enough to warrant the millions necessary to produce a secure and compatible framework for all this stuff. Thanks for speaking sense.

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